Issue 39
July, 2018
Welcome to Synergy
We are pleased to present the thirty-nine issue of Synergy, a monthly newsletter about the progress and processes of the Suffolk Care Collaborative (SCC).

The definition of synergy is the increased effectiveness that results when two or more entities work together. We are confident that the combined efforts of the many dedicated partners within the SCC will help the Collaborative reach its goals, leading to improved health for the residents of Suffolk County.  

About Suffolk Care Collaborative (SCC):  SCC is an alliance of healthcare providers in Suffolk County, Long Island, NY, formed to support New York State's Delivery System Reform Incentive Payment (DSRIP) initiative. Under the guidance and leadership of Stony Brook Medicine, SCC established a Population Health Management Service Organization to improve county-wide health by addressing a wide range of challenges to health in order to improve outcomes by encouraging wellness, making healthcare more accessible and reducing costs by decreasing unnecessary hospital utilization.  For more information, visit our website:

In This Issue
SCC Partners Implementing Process Improvements for Lasting Change

Partners of the Suffolk Care Collaborative (SCC) are championing efforts to learn and implement evidence-based methodologies to support achieving DSRIP goals and milestones. Recently, two of SCC's partners focused on process improvement and implementing lasting change by participating in the Medicaid Accelerated eXchange (MAX) Series and Lean Training. The SCC supported these initiatives.  
Federation of Organizations (Federation) is a multi-service, community-based social wellness agency and is a major provider of health and wellness, senior and children's services, housing and support services in Suffolk, Nassau, Queens, Brooklyn, Bronx and Manhattan. Federation participated in the MAX Series to reduce unnecessary hospitalizations and readmissions for multi-visit patients in the behavioral health population. MAX focuses on local process improvement for specific patient populations to affect DSRIP quality measures and improve the health of the community. To accomplish this, Federation assembled an implementation team made up of members in the organization who were empowered to make decisions quickly. The team included administrative and clinical program leadership, supported by Susan Jayson, LCSW, SCC Director of Behavioral Health Integration.

The first step in the performance improvement approach was for the team to identify their target population -- those clients that frequently utilize hospital services and identify why they are going there. They then developed a real time notification of healthcare by using Healthix, their Regional Health Information Organization (RHIO), to receive alerts; embedded Healthix and PSYCKES into their client intake process; and implemented flags in their electronic health record to identify high-risk individuals. Using data and speaking with their clients, they discovered that unnecessary hospital visits stemmed from the lack of connections to primary care providers and medication management related to obtaining refills. Therefore, connecting individuals to community resources was key to getting them the right care and providing an alternative to unnecessary hospital visits.
The sample size for this MAX Series was small, which gave Federation an opportunity to follow and focus on these individuals and monitor success over a 12-month period of time. In this cohort, 100% were successfully linked to primary care, only 3 clients out of 12 subsequently returned to the hospital, and 100% of the individuals remained out of the emergency room for medication refills with 50% eligible for home medication delivery. "The series was helpful in supporting individuals' adherence to the plan of care, focusing their treatment and implementing a service that really works for them," according to Jason Vandewater, LCSW, Director of Clinical Services at Federation, one of the MAX Series team members.
East Hampton Family Medicine , a small independent community-based family medicine practice that serves a very diverse patient population, engaged in Lean training and focused on a performance improvement project targeted at improving care for their patients with diabetes. Lean training, conducted by Alan Cooper, PhD, President, Tudor Advisory Group, Inc., is an ever-evolving philosophy based on proven principles and practices aimed at the elimination of waste; employing practices that will improve an organization through an evidence-based methodology.
The Lean methodology uses team members that touch the process the most to make improvements. The East Hampton Family Medicine team got to work mapping the current workflow, identified waste within the process and then implemented improvements for future workflows. Their Lean project specifically aimed to improve diabetes care. They identified gaps in care and the barriers to care delivery for patients with diabetes, then implemented workflows and created chart alerts to address gaps.
Through the Lean process, specific issues were resolved, including a workflow to refer patients to ophthalmology care. The practice established a working relationship with a local ophthalmologist's office that accommodates their patients the same or next day and sends consult notes to the practice within 24 hours of consultation. Additionally, barriers such as patient non-adherence or lack of understanding of their diabetes diagnosis led to the establishment of group meetings for patients with diabetes, held monthly in English and Spanish. The meetings have been well received by their patients and has led to an increase in adherence. There has been a lot of support from staff and professionals in the community, including certified diabetes educators and a local ophthalmologist, who attend the meetings to provide important education.   They also teamed up with a local pharmacist who has provided glucometers to patients that do not have insurance to cover the cost.

"The new workflows and initiatives have increased efficiency and we are on track to surpass diabetes care goals for 2018," as noted by Douglas Kronenberg, Practice Administrator. The newly learned techniques were also employed to help improve other DSRIP, HEDIS, MIPS and insurance company measures in the practice.
To view detailed presentations about these two projects, visit the SCC website .
Quality and Performance Improvement for Behavioral Health Training

Earlier this month, the Suffolk Care Collaborative (SCC) hosted a full-day Quality Improvement training for Behavioral Health Agencies dedicated to applying quality improvement tools, techniques and strategies in the behavioral health setting to improve performance. The agencies were encouraged to bring an interdisciplinary team, as much of the day's activities were intended to support the formation of a quality improvement team or strengthen existing quality improvement teams.

The training contained several presentations by staff at the SCC including an overview of the SCC DY4 priorities and strategies by Kevin Bozza, Chief of Operations & VP, Population Health Management Services; an overview of performance attribution and action plans by Christopher Ray, Administrative Manager, Performance Reporting & Management; review of the Institute for Healthcare Improvement's Model for Improvement and other quality improvement tools by Ashlee McGlone, Provider Relations Liaison, and Alyse Marotta, Administrative Manager, Behavioral Health Programs; review of the measures aligned to the behavioral health agencies by Janine Muccio, Performance Management Assistant, and a PSYCKES use-case refresher presented by Christopher Ray and Ashlee McGlone.

Additionally, Jason Vandewater, LCSW, Director of Clinical Services at Federation of Organizations, presented on their participation in the MAX Series which successfully reduced unnecessary hospitalizations and readmissions for a cohort of multi-visit clients using some of the skills and resources covered throughout the day.  Jason emphasized the point that performance improvement does not need to be difficult, a focused and strategic approach to quality improvement can effectuate meaningful change.

This training was a great opportunity to engage behavioral health agencies in performance improvement as we enter measurement year 5 and work to improve the PPS performance measures aligned to behavioral health. To close out the training session, teams began to develop a quality improvement strategy for their own agency and shared their planned approach with those in the room. Going forward, the SCC will work with these agencies to link their strategy to action plans and support the agencies in meeting their improvement goals.
SCC's Your Care, Everywhere Brochure

Suffolk Care Collaborative (SCC) continues to be involved in a variety of efforts to educate, engage and empower community members on health and wellness. As providers increasingly utilize information technology like a Regional Health Information Organization (RHIO), which is the entity that enables the sharing of information among various provider settings,  SCC has identified an opportunity to educate communities on the benefits of such technology in their health care management. The Your Care, Everywhere: RHIO Client Consent Form Frequently Asked Questions (FAQs) brochure was created to share with patients and clients to increase knowledge on the purpose of RHIOs, as well as learn how to complete the client consent process. The brochure was created in collaboration with SCC's Cultural Competency and Health Literacy Information Technology (CCHL IT) Subgroup, IT Taskforce and other partners. Furthermore, the brochure was reviewed and endorsed by the SCC CCHL Advisory Workgroup to ensure the content meets nationally recognized cultural and linguistic standards.

To view, download and share the Your Care, Everywhere brochure, please visit SCC's website. Feel free to share your feedback with the SCC Community Engagement Team, or ask questions by emailing:
Stony Brook Diabetes Center Offers Patients Empowerment Through Education 
Written By Patty Skala, RN, MA, MSN, CDE, BC-ADM
Quality Coordinator, Stony Brook Medicine Self-Management Education Program

As of 2018, more than 30 million Americans have been diagnosed with diabetes and 89 million Americans have been diagnosed with prediabetes; a condition where blood glucose levels are higher than normal but not yet high enough to be diagnosed with diabetes, as cited in The Journal of Clinical and Applied Research and Education. These statistics include the patients with a known diagnoses. There are many more people in the country with undiagnosed diabetes and prediabetes. If these trends continue, as many as one in three Americans will have diabetes by the year 2050. On any given day, approximately a quarter of the patients admitted to Stony Brook Hospital have either a primary or secondary diagnosis of diabetes.

Stony Brook Diabetes Center has been recognized for its excellence by the American Diabetes Association (ADA) since 1996. The program is diverse and consists of a team of endocrinologists, nurse practitioners, registered nurses, registered dieticians, endocrine fellows and residents. The center has four certified diabetes educators (CDEs) and one board-certified advanced diabetes manager (BC-ADM). The diabetes program offers both individual consultations and group classes throughout the year at Stony Brook Hospital. Information regarding details and upcoming class schedules can be found here.  

Diabetes Self-Management Education and Support (DSMES) is performed by healthcare professionals who have appropriate credentials and experience consistent with each profession's scope of practice.  To be eligible to sit for the CDE exam, one must have 2 years of recent experience in their profession, a minimum of 1,000 hours in the field of DSMES, and a minimum of 15 continuing education credit hours related to diabetes in the two years prior to applying.  There are review classes and workshops both online and in person throughout the country to help professionals gain the knowledge and credits needed to become a CDE.  Details for eligibility can be found on the American Association of Diabetes Educators (AADE) website.  We are in the midst of a worldwide diabetes epidemic and people with diabetes need our help.  Not only do we need more diabetes experts in Suffolk County, but we need more worldwide. Personally, I feel that one must have a strong passion for working with this population.  It is a rewarding field of work, however, it is fast-paced and involves continuous changes in medications and technology. One must have the desire to keep up with the research and face the challenges that come with advances in the field.  I recommend joining two associations to keep up to date in the field of diabetes:  The American Diabetes Association and the  American Association of Diabetes Educators.

Stony Brook Medicine's (SBM) diabetes education services reach the DSRIP population and the community through ongoing assessment of the community's needs and targeted marketing. Our marketing team visits medical offices throughout Suffolk County and introduces them to our services. The community outreach coordinator assists with involving the diabetes team in community engagements. SBM takes care of many uninsured patients from the community. Many of these patients speak languages other than English. Through individual communication with Suffolk Care Collaborative (SCC) and DSRIP quarterly meetings, we strive to improve the overall health of the population by addressing health challenges as a team. The goal is always the same, "To educate as many people with diabetes and prediabetes as possible in order to help patients avoid the devastating complications of the disease." SBM and SCC work together in collecting and analyzing data and spreading awareness to the communities we serve. All healthcare systems on Long Island need to work together and collaborate during this diabetes epidemic.  SCC is central to this collaboration.

Diabetes education has many benefits. We educate patients with diabetes on subjects such as the diabetes disease process, nutritional management, physical activity, blood glucose monitoring, medications, acute and chronic complications, coping with the disease, problem-solving and standards of care. Our classes have guest speakers which include endocrine fellows, nurse practitioners, registered dieticians, physical therapists, registered nurses and motivational speakers. The day class includes a carbohydrate counting lunch. Ideas for future speakers include a pharmacist, an ophthalmologist, a podiatrist and an orthopedist. In the last two years SBM's class statistics revealed that participants lowered their hemoglobin A1cs (HbA1c) by 1.9% and 1.8% respectively. Many class graduates were able to decrease their HbA1cs to the 6 range and decrease their medication usage. In some cases, participants with type 2 diabetes were able to decrease or stop using insulin, primarily through healthy lifestyle changes. The goal for our diabetes education team is to encourage patients to incorporate healthy lifestyle changes into their lives for the long-term.

Visit the website for details about upcoming classes and click here to access the physician referral form.  A ll patients must schedule a one-on-one assessment visit prior to attending classes. Call 631-444-0580 to schedule an appointment. For questions please call Patty Skala at 631-444-9954.
Resources to Help Improve Patient Experience 

To gain a better understanding of the uninsured and Medicaid population's experiences with providers and office staff during the course of their care, two Consumer Assessment of Healthcare Providers & Systems (CAHPS) surveys for Clinician and Groups (CG-CAHPS) are administered annually.  The Suffolk Care Collaborative administers the CG-CAHPS survey for the uninsured population and the New York State Department of Health (DOH) administers the CG-CAHPS survey for the Medicaid population.

The survey distributed by the DOH for the Medicaid population includes 13 measures which assesses the primary care service:  the patient's access to timely appointments, care and information; the provider's use of information to coordinate patient care; the health literacy of instructions and clinical measures such as aspirin use, flu shots; and medical assistance with smoking and tobacco use cessation.

The DOH samples and administers surveys from September through December of each measurement year.  Adults ages 18 to 64 who are current Medicaid members, enrolled continuously for six months and who have had at least one qualifying outpatient visit in the last six months as of July are eligible to receive the survey.

In measurement year three, the SCC met 6 of the 13 measures. There is a need for focus to close the gaps related to the following survey questions:
  • Q6. Usually or always got appointment for urgent care as soon as you needed
  • Q8. Usually or always got appointment for non-urgent care as soon as you needed
  • Q10. Usually or always got answer to medical question the same day you contacted provider's office
  • Q18. Provider usually or always gave easy to understand instructions for caring for illness or health condition
  • Q35. Take aspirin daily or every other day
  • Q37. Doctor has discussed risks and benefits of aspirin to prevent heart attack or stroke
Additionally, there is an opportunity to meet high performance for:
  • Q33. Doctor or health provider recommended or discussed medication to assist with quitting smoking or using tobacco
Resources for improving patient experience can be found in the "For Partners" section of the SCC website and can be accessed by clicking on topics below:

  • Open Access Scheduling
  • Share-Decision Making
  • Teach-Back
  • Improve Telephone Access
  • Assess, Select and Create Easy-to-Understand Materials
  • Make Referrals Easy

Partner Interview:  Asthma Education 
Name:  Lisa Romard, CPNP, AE-C 
Title:  Nurse Practitioner 
Organization:  Stony Brook Children's Hospital

Please describe your role in Asthma Education in your organization.
Since my earliest years of employment at Stony Brook (SB) as a Registered Nurse I was interested in working with children with asthma and respiratory diseases. I have worked at SB in the department of pediatrics since 1984, always including a focus with children's respiratory health. I worked in the SB pediatric ICU and was very much motivated to teach families of children with asthma about asthma and self-management to improve their quality of life. I started an asthma support group for parents of children with asthma and for the children to learn about asthma in the 1980s.  I transferred to outpatient care and continued to work with this population through our division of pediatric allergy for a number of years, learning more about the effects of allergies and environmental exposure that can trigger asthma symptoms and affect a child's asthma control. After obtaining my advanced nursing graduate degree and NYS licensure as a pediatric nurse practitioner (NP) in 1999, I was hired as the NP for the Stony Brook Children's (SBC) pediatric pulmonary and allergy division. In 2010, I obtained the National Asthma Educator Certification Board (NAECB) national certification for asthma educators (AE-C) and have worked consistently as a pediatric NP and Asthma Educator throughout the years with asthma patients and their families at SBC Hospital.
What is a Certified Asthma Educator?
Certified asthma educators are those who have meet the requirements to sit for the national certification exam. They can be licensed healthcare professionals, or individuals who have provided direct asthma counseling/education/care coordination with a specified number of experiential hours in the field. These individuals have been specially trained and educated about all aspects of asthma, including asthma self-management strategies, addressing barriers and disparities that potentially add risk for a patient's asthma self-management, and strategies to communicate effectively with patients with asthma and their families. Asthma educators help patients learn the best ways to keep their asthma under control and focus on helping patients learn effective asthma self-management skills.  After specialized training and passing the national comprehensive certification exam an asthma educator can then follow the guidelines of an AE-C provided by the NAECB for practicing in their area of expertise.
How do your education services reach the DSRIP population?
My role as the SBC's Pulmonary NP includes inpatient asthma consultation and education for children and families admitted with asthma who are identified as needing specialist care, care coordination, attention to high risk factors and a need for asthma education.  I follow these patients both in the hospital, as well as in the outpatient office setting with the pulmonologists.
I provide asthma education sessions with patients and families at various points in their asthma care through SBC:  inpatient, outpatient, telephonically and with the assistance of health programs in the community.  In the hospital during the admission for asthma, families are encouraged to attend the asthma education class that is given daily by SB respiratory therapists.  I offer and deliver asthma education depending on the needs of the patient and family after I assess their knowledge and needs. We have a one to one session, if needed an interpreter is present to assist to address language barriers. I adjust my education session for each to focus on the needs of each patient and delivery is based on what is felt to be best for their understanding of the material and information. I utilize asthma education materials that are approved by SB patient education committee and the Asthma Coalition of Long Island that are at appropriate health literacy levels and in different languages.
Describe the benefits asthma education provides to patients.
Asthma education has been shown to improve a person's ability for self-care and asthma management. The National Institute of Health (Guidelines for the Diagnosis and Management of Asthma - EPR-3)  lists asthma education as a partnership in care as one of the 4 major components of the national guidelines. The benefits of asthma education includes the opportunity to provide a patient/family with information they may not have received, clarification of information provided at previous health encounters, or new information needed due to changes in their plan. The goals for asthma education are to increase a person/family member's knowledge about asthma & self-care management, improvement in medication adherence and symptom control, reduce risks for exacerbations and need for high level medical care, improve inhaler technique and proper use of medications prescribed, and ability to utilize a written action plan.  In addition, asthma education aims to improve quality of life measures for those with asthma not well controlled, such as activity tolerance, sleep and the ability to participate in usual activities such as school and work.
How have you been involved in SCC'S Promoting Asthma Self-Management Program (PASP)?
I assist in the healthcare, care coordination and asthma education for DSRIP patients and families. I have participated in the development of the SBC asthma home visit program, the educational materials used, educating and certifying the community health workers for their ability to offer asthma education. This program offers a valuable in-home asthma assessment of needs and triggers, care coordination, education and identification of barriers that are addressed to ultimately improve asthma control and quality of life measures.
For helpful asthma education material, use the below links:

Compliance Connection
Medicaid Member Fraud

Compliance programs tend to focus their Medicaid fraud detection and prevention activities on providers. However, fraud may also be committed by patients enrolled in Medicaid (also called recipients or members); therefore, compliance activities should also address this risk. Examples of enrollee fraud include:
  • Lending or sharing a Medicaid Identification card
  • Forging or altering a prescription or fiscal order
  • Using multiple Medicaid ID cards
  • Re-selling items provided by the Medicaid program
  • Selling or trading the card or number for money, gifts or non-Medicaid services
Enrollee fraud costs taxpayers money and can waste valuable healthcare resources.  A number of governmental agencies investigate member fraud, and the consequences can be severe.  SCC partners and their employees should be alert to signs of potentially fraudulent Medicaid member activities.   Everyone has a duty to report actual or suspected concerns affecting DSRIP funds.  To report fraud directly to the NYS Office of the Medicaid Inspector General (OMIG) call 1-877-873-7283 or click here to report online.  Learn more at the OMIG Fraud/Abuse webpage.  

If you have questions talk to your compliance officer or contact SCC's Compliance Office at
 Milestone Dates
 NYS DOH DSRIP Program Milestone Dates
August 30
IA completes review of PPS DY4 First Quarter Report
September 14
PPS Remediation of PPS DY4 First Quarter Report

Frequently Asked Questions


To access NYS DSRIP FAQ, click  here.
Access previously published Synergy eNewsletters  here
Job woman showing hiring sign. Young smiling Caucasian   Asian businesswoman isolated on white background.
Office of Population Health
Career Opportunities
The SCC is pleased to invite qualified career seekers to apply for open positions. All job descriptions for current opportunities are posted here.

Current Job Opportunities:
  1. Director, Behavioral Health Services Integration
  2. Care Manager
  3. Social Worker
  For more information, please contact the Suffolk Care Collaborative via email